One of the most demanding challenges within policing, but especially when dealing with mental health issues, is the need to make black and white decisions from situations involving endless shades of grey. Police officers, by virtue of their role, are frequently making decisions which amount to gambles because they often don’t know all that they would prefer to know when making professional choices.
Let me give just two examples:
- The Investigation of Crime
- If someone is arrested for an offence and appears to be suffering some kind of mental disorder, the custody sergeant would, of course, get health and social care professionals involved to assist in helping, assessing, signposting, etc.. Once this is done, the sergeant will be required to make decisions about that criminal allegation – firstly, about whether there is enough evidence to charge someone with an offence; but also around whether to divert the person from justice (whatever that means) or to prosecute them into the criminal courts – the public interest test.
- However, that sergeant will often not be told details of the healthcare assessment. Indeed, sometimes the health professionals themselves will be operating blind, because it could be out of hours and the patient from another area of the UK when little can be established about their health background. How confident are you now about whether to criminalise someone further or to divert them from the cells?!
- Ensuring Appropriate Medical Care After Arrest
- Where police officers detain people under mental health law who are in need of care or control, they are often dealing with people who are resistant or intoxicated. We know from hard lessons that resistant presentations can be attributable to other medical conditions like head injury, diabetes or epilepsy and we know that alcohol can mask symptoms or cause premature conclusion that someone is “just drunk”.
- Where as a police officer you know your A&E will say “We’re not a place of safety” and your ambulance service will say that you “don’t need an intensive care unit on wheels for a 136?!”, you are left to gamble, sometimes with that person’s life and wellbeing. Not a great place to be!
So how to you turn these endless shades of grey into black and white? These hypothetical situations are chosen deliberately. In the first case, it is easier to stall the decision by using police bail to find out more. In the second, if you get that wrong, you will be accused of professional shortcomings and there is no way to stall the decision. In the first case, you take time to find out more; in the second, you err on the side of caution and take the ‘careful’ option.
In other words, it’s about risk assessment, isn’t it? By this, I don’t mean that it is about filling in reams of paperwork to document a range of issues. There is a simple model that I use in a range of situations at work, which was taught to me by an engineer(!) and was used by him in the construction of some seriously well know buildings:
PROBABILITY x THREAT = RISK
- Low probability of a small threat being realised, you are dealing with low risk situations.
- High probability of a small threat being realised, you are dealing with something you must take more seriously.
For example, if assessment of a building plan concluded a real, but low, probability that the building will fall down with people in it, you would revisit the plans! If there was a high probability that the building’s cosmetic exterior would not maintain its shiny appeal because of weather damage, you may decide to just roll with it and build in a maintenance programme.
The problem situation which bedevils decision-making around policing and mental health is: very low probability of a significant threat being realised. For example, there are over a million arrests a year in the United Kingdom and in that context, deaths in custody or following police contact are statistically rare. Having said that, there are some obvious warning signs and predictors and drugs and alcohol, resistance and mental ill-health are right up there with the best of them.
The investigation and / or prosecution of offenders with mental health problems is as complex as it gets but it is often not time critical. Police officers and CPS are weighing up, the strength of the evidence, the victim’s wishes, the public interest in preventing any further offending alongside that information, potentially incomplete, about the offender’s mental health; their level of engagement with mental health services, if any; the impact upon the individual of being prosecuted or not prosecuted. Not easy, is it? What if you didn’t know a nugget of information that was crucial about threats and risks?
There may always be the possibility of a serious untoward event after someone is detained under mental health law. This could come from the underlying condition itself, from the consequences of any restraint that became necessary or because of action taken by that person after arrest, for example to self-harm. It’s always possible someone may die in custody, but it’s very, very unlikely that they will. How do we identify which should go to custody anyway and get an FME, which should go to A&E to see someone far faster or for an intervention that cannot be provided by an FME in a police station?
Both of these situations can benefit from the kind of risk model, above; simple though it is. Determine the risk in the situation by balancing probability versus threat. Deal with “unknown unknowns” according to the scale of risk you are determining. So where you are pondering someone’s safety in custody because of the potential for drugs or aggression to be masking a medical condition, call an ambulance and / or remove the person to A&E for advice in the paramedics think it is needed. If the risks and threats around diversion (whatever that means) are less serious or not indicated, you may be more inclined to use bail before charging someone, to give the police and the NHS time to find out more.
You can’t mitigate all risks – you have to run with some of them. The trick is to spot the low probability but high impact events and take steps to mitigate those, because it’s at the heart of public confidence in policing – especially where it will always be said in hindsight, that it could or should have been predicted.
The Mental Health Cop blog won the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”